DEBARK HOSPITAL

ACCEPTANCE TEST LOG SHEET

Name/type/of equipment:-------------------------------------------- Order no:-----------------------------
Type/model: ---------------------------------------------- Serial no: - ------------------------------
Cost: -------------------------------------------------------- Date of received: ----------------------
Supplier/agent name and address
---------------------------------------------------------------------------------------------------------------------
Phone:---------------------------------------------------------------------------------Fax------------------------------------------------------------------
Email:---------------------------------------------------------Delivered person
Name------------------------------------------------------------- phone---------------------------------------
Manufacturer address
---------------------------------------------------------------------------------------------------------------------
Phone-------------------------------------/---------------------------------------/-----------------------------/--
Fax------------------------------------------/----------------------------------- Email:------------------------------------------------Maintenance contact
with----------------------------------------------------------------------------------------------------Warranty expiry
date:---------------------------------------------------
Received person
1. Name:------------------------------------- Professional------------------------Sign-----------------
2. Name--------------------------------------Professional ----------------------Sign-------------------
Allocated inventory no: -----------------------------------------Destination location: --------------------

DELIVERY
Under taken by:------------------------------------------------------------------------------------------------------------ Witnessed by:-
Name------------------------------------------------------------------------------------------------------------------------------------------------------------------
Position--------------------------------------------------------Sign-------------------------------Date-------------------------------------------

Condition needed Yes/done No /not done Corrected if applicable

a. Representative of supplier present?
B.CorrectNo, of boxes is received?
c.After unloading, visible damage to the boxes?
d.If damage, has this been stated on the delivery
note and senior management informed?
Comments---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-

ASSEMBLY
Under taken by:--------------------------------------------------------------------------------------------------Witnessed by:-
Name--------------------------------------------------------------------------------------------------------------------------------------------------------------
----Position-------------------------------------Sign-------------------------------Date--------------------------------------------

Condition needed Yes/done No /not done Corrected if

applicable
a. Are all parts available?
b.Do they fit together?
c.Main lead with plug included?
d.Do all accessories fit?
e. Are marking and labels ok?
f.Any damage?
Comments-----------------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------

INSTALLATION
Under taken by:--------------------------------------------------------------------------------------------------Witnessed by:-
Name------------------------------------------------------------------------------------------------------------------------------------------------
Position-------------------------------------------------------Sign-------------------------Date---------------------------------

Condition needed Yes/done No /not done Corrected if applicable

a. Was the work carried out satisfactorily?
b. Were technical staffs present as learners?
COMMISSIONING/TESTING
 Under taken by:------------------------------------------------------------------------------------------------------------ Witnessed by:-
Name--------------------------------------------------------------------------------------------------------------------------------------------------------------
Position------------------------------------------------------------Sign------------------------Date-----------------------------------------

Condition needed Yes/done No /not done Corrected if

applicable
a. Were Electrical, mechanical, gas, radiation
safety tests and performance checks carried
out?
b. Was the work carried out satisfactorily?
C. Was technical staff present as learners?
d. Were the operators present as learners?
Comments-----------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
---

Electrical integrity
Under taken by:------------------------------------------------------------------------------------------------------------ Witnessed by:-
Name-----------------------------------------------------------------------------------------------------------------------------------------------------------------
Position---------------------------------------------------------Sign-----------------------------Date-------------------------------------------

A) Class 1- 2- 3? B) Type B- BF-CF? C) Type AP-APG?

Mains connection
a) Are cables and cables intact?
b) Is cable color code correctly connected?
c) Are connectors intact?
d) Are fuses correct?
e) Is equipment protection correct?
f) Is voltage setting correct?
g) Is there an earth terminal?
Electrical measurements
a) Is protective earth continuity correct?
b) Is insulation resistance correct?
c) Are the leakage currents correct?
d) Is the voltage measurement correct?
e) Is the power consumption correct?
Comments---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-

Radiation integrity tests

Under taken by:------------------------------------------------------------------------------------------------------------ Witnessed by:-
Name-----------------------------------------------------------------------------------------------------------------------------------------------------------------
Position---------------------------------------------------------Sign-----------------------------Date-------------------------------------------

a) Is the KV calibration correct?

b) Is the mAs calibrated correctly?

c) Was the line voltage compensation performed?

d) Was the exposure test correct?

E) Were the small and large focus calibrations done?

Comments---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-

Performance test
 Under taken by:------------------------------------------------------------------------------------------------------------ Witnessed by:-
Name-----------------------------------------------------------------------------------------------------------------------------------------------------------------
Position---------------------------------------------------------Sign-----------------------------Date-------------------------------------------

a) Are the function verification tests correct?

b) Is the equipment calibration acceptable?

Comments---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-

ACCEPTANCE (to certify by the head of Equipment maintenance only)

Condition needed Yes/done No /not done Corrected if applicable
a. Is equipment accepted?
b. If rejected have the short coming been
summarized as on page 12 0f this form?
c. If so has a report gone to senior management
and formal compliant procedures started?
d. should payment be with held pending
correction?
E. Is payment approve?
Comments---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------

TRAINING
Under taken by:------------------------------------------------------------------------------------------------------------ Witnessed by:-
Name-----------------------------------------------------------------------------------------------------------------------------------------------------------------
Position---------------------------------------------------------Sign-----------------------------Date-------------------------------------------

Condition needed Yes/done No /not done Corrected if applicable

a. Were the expected training course given?
b.Were the training courses satisfactory?
c. Were suitable operator’s person?
d. Were suitable technical staffs present?
Comments---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-
ACCESSORIES RECIEVED

1. ------------------------------------------ 2. ----------------------------------------3. ------------------------------------

4. -------------------------------------------5. ----------------------------------------6. -----------------------------------

CONSUMABLES RECIEVED

1. -------------------------------------------2. -----------------------------------------3. ----------------------------------

4. -------------------------------------------5. ------------------------------------------6. ---------------------------------

SPARE PARTS RECIEVED

1. -------------------------------------------2. -------------------------------------------3. --------------------------------

4. -------------------------------------------5. -------------------------------------------6. --------------------------------

MANUALSRECIEVED

1. ------------------------------------------- 2. ------------------------------------------- 3. -------------------------------

4. --------------------------------------------5. ------------------------------------------- 6. ------------------------------

FAULT REPORT
(Describes any short coming with equipment or service provided)

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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--------------------------

PERSON WHO VERIFY THIS FORM

Name Signature Date

1. --------------------------------- ------------------------------ -------------------------------

 Debark general hospital
Biomedical service report
No Name of MEs Model Supplier ME status Reason for not Corrective Quantity Remark
Fun action taken
Fun Not Fun
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28
Reported by phone number date